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The Current Transcript for March 8, 2018

Host: Anna Maria Tremonti

STORIES FROM THIS EPISODE

Listen to the full episode

Prologue

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I don't know how my daughter who is 14 asked me this but she asked me if I had violated the Hippocratic Oath. And of all the times that I talked about this operation nobody had asked that.

ANNA MARIA TREMONTI: He went into the operating room that day knowing that what his surgical team would do would likely end a life, and save a life. They had committed to separating conjoined twin girls not even aware that 20 other hospitals had turned them away. It was medically, physically, ethically challenging and by the end all Dr. Allan Goldstein could do was cry. But somewhere in and around Boston today there was a healthy little girl who remembers the sister she used to have. In an hour, we'll bring you a story you will not forget. Also today, a different kind of medical challenge.

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You look at something like prostate cancer, it's so easily detected. Getting screened, getting tested, these are the things that give you a chance to at least catch something wrong and it may save not just your lives but also the people that love you.

AMT: The push for the PSA test for prostate cancer comes from athletic stars and familiar voices. But a new study involving more than 400,000 men is pushing back concluding that men who don't already have symptoms not only don't need the PSA test, they put themselves at risk if they get it. The lead researcher on that study explains what he found in half an hour. And Britain's foreign secretary was not naming names

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Though I'm not pointing fingers, I say to governments around the world that no attempt to take innocent blood on UK soil will go either unsanctioned or unpunished.

AMT: But when a former Russian double agent is poisoned with a nerve agent in a quiet British neighborhood the speculation turns to the Kremlin especially when it fits the Putin pattern. We're starting there. I'm Anna Maria Tremonti. This is The Current.

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Suspected poisoning of former spy is a warning to the West, says expert

Guests: Amy Knight, Luke Harding

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I saw something I was not supposed to. They gave me a choice: Die or become a sparrow.

AMT: Well that's from the Russian spy movie Red Sparrow in theaters now. On the streets of England this week a real life spy drama has been unfolding. Former agent Sergei Skripal and his 33 year old daughter Yulia are in critical condition after being found Sunday slumped over on a bench in Salisbury, the English town where Mr. scribal lives.

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In Salisbury, this is being treated as a major incident involving attempted murder by administration of a nerve agent.

AMT: Some of yesterday's update on the case from British officials. For more I'm joined by Luke Harding he's a reporter for The Guardian and the author of Collusion: Secret Meetings, Dirty Money and how Russia helped Donald Trump win. Luke Harding is in London, England. Hello.

LUKE HARDING: Good morning.

AMT: Well first of all how are Sergei Skripal and his daughter Yulia doing right now?

LUKE HARDING: Well they are critically ill still. They remain in intensive care. She was airlifted to hospital by helicopter. He was driven there and the situation is clearly very grim. We also know that a police officer. Who was the first at the scene who discovered them in a comatose state, has also been very kind of seriously affected apparently. He's talking this morning but he was a kind of incidental target. And it's interesting you began with Red Sparrow the movie. This is an extraordinary story and of course we in Britain have seen this movie before with the assassination in 2006 of Alexander Litvinenko, another Russian spy who back then was poisoned with a radioactive cup of tea.

AMT: Hmm. You covered that.

LUKE HARDING: Yes I wrote a book about that called A Very Expensive Poison and what's interesting is I think now, after we have confirmation from Scotland Yard from the police in London that a nerve agent was used, that everybody will be looking towards Moscow because this isn't the kind of substance you can get from a drugstore or you can assemble on the Internet. It's really something any state would get hold of. And you have to ask who would have the motive and who would have the means to do this to specifically deliberately target a 66 year old former spy and his daughter over visiting from Moscow.

AMT: Luke, is there any information at all on how that nerve agent might have been administered

LUKE HARDING: Well, no. It's very mysterious. Apparently the British government know what it is that they are not saying but my understanding is that once they have that kind of fingerprint they can figure out from which country it has come and possibly even from what laboratory. But in terms of how it is deployed it could have been an aerosol. It could have been food. It could have been all manner of things. We've had a a British pub and a pizza restaurant which has been sealed off where Yulia and Sergei were visiting before the attack happened but I think at this stage we don't know. And there are hundreds of detectives going through CCTV images including a very curious one of a couple seen around the time of the incident walking past a fitness center to try and get leads.

AMT: And so we don't know because some of these nerve agents can linger, can they not? Again we don't know which one it is.

LUKE HARDING: Well they can and I think if we start from the assumption that this may have had state involvement, if you just take a step back it's an extraordinary thing. It's a brazen thing. I mean this isn't even in London. The planning of an attack on Alexander Litvinenko took place in a five star Mayfair Hotel. This is a very ordinary cathedral city with a shopping center and a park. And people just relaxing on a Sunday afternoon. And the fact that an assassin could go in there kill or attempt to kill a couple of targets and escape is remarkable.

AMT: And we see on the wires that a spokesperson for the Prime Minister Theresa May has called this incident appalling and reckless. like Litvinenko, I mean there was radioactive material kind of a little trail of it after, was there not, when they poisoned his tea?

LUKE HARDING: Well there was. Polonium is a highly unusual radioactive substance you can only get if you have a nuclear reactor which of course private individuals don't have. I think the trail in this case will be smaller. The advantage the police have is that they were quick to the scene. With the Litvinenko case it took 23 days for the British authorities to work out what on earth it was that had caused Litvinenko hair to fall out to get from these terrible symptoms where it. Whereas this case they've identified the substance but you have to imagine if this was a state plot it would have been very well organized and the assassins, whoever he or she or they are, will be long gone.

AMT: And so of course the British government is being careful not to name Russia. But are there other possibilities? Who could it be?

LUKE HARDING: Well the people I talk to who are former people from the intelligence world are skeptical that this could have been done on a freelance basis. And if you look at Vladimir Putin's state the timing is odd, it comes just before a presidential election which Putin will win. He'll get another six years in power. That is a foregone conclusion. But there is a tradition of the KGB and the FSB spy agency poisoning people it regards as traitors. And second Skripal was very much one of those he worked for Russian military intelligence the GIU for a long time. He was allegedly recruited by MI6 in 1995 and gave away the identities of dozens of agents. And if there is a message here I think the message is 'we don't forget we don't forgive and we can get you if we want at a time and place of our choosing'. And that's pretty chilling for anybody inside the Russian bureaucracy who's thinking about cooperating with the Americans or the Canadians or British intelligence. There is a huge price to pay.

AMT: So and if Russia is behind this, what does it mean for relations between the British government and the Kremlin?

LUKE HARDING: Well I mean they've been lousy for some time. They were really in the deep freeze. After the Litvinenko case Putin said he had nothing to do with it. He refused to extradite the two killers. And then finally in 2016 had a public inquiry which confirmed this was a staged assassination and that Putin had probably approved it himself. That was the legal finding and I think it's interesting because Theresa May the British prime minister what can she do. She just doesn't have a huge number of options and bear in mind that the UK is exiting from the European Union because of Brexit. So we don't have a huge number of allies on the continent and we have an American president who himself seems to some degree to be under Russian influence, so there is going to be no back up there. And one thing Vladimir Putin is very good at is exposing weakness. He knows the UK is weak. He knows that there is not a huge amount we can do. Boris Johnson talked about not getting to, the World Cup soccer championship to be hosted by Moscow this summer. Well that's not really going to strike terror into the Kremlin, is it?

AMT: So what questions do you still have?

LUKE HARDING: Well I would like to know what the toxin is. Once we have that we can we can be more authoritative about where it came from. But I think as with the Litvinenko case as I think this is going to be and for the long haul that we will probably get the forensic evidence in this country. But what we won't get - and you and I may be on the zimmer frames before we do get it - is what happened in Russia; who gave the order, which operatives carried it out, did Putin approve it? And so them for that, we'll have to wait until the end of the Russian regime and that could be quite a long time.

AMT: Okay Luke Harding thanks for your insights. That is Luke Harding he's a reporter with The Guardian. He's the author of Collusion Secret Meetings, Dirty Money and how Russia Helped Donald Trump Win. Luke Harding joined us from London, England. Now of course the use of poison is hardly unknown when it comes to eliminating opponents of the Kremlin. Just last month here on The Current I spoke with Vladimir Kara-Murza an outspoken critic of Russian President Vladimir Putin who says he survived two poisonings. Here is part of how he described the experience of being poisoned.

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I was at a work meeting. I was in Moscow it was in May of 2015. And suddenly I began to feel very very sick for no apparent reason and within the space of under an hour I went from feeling completely normal like I am now to basically being incapacitated. You know my heart started racing, I suddenly had difficulty breathing. Within a couple of days all of my major body organs shut down in a cascade one after another. I was in a coma, on artificial life support. Doctors told my wife that I had about a 5 percent chance to survive.

AMT: Well Amy Knight has studied assassinations and assassination attempts in the age of President Putin. She is a contributor to The Daily Beast. She is an expert in Russian politics and her new book is called Orders to Kill: The Putin Regime and Political Murder. Amy Knight joins me from Summit, New Jersey. Hello.

AMY KNIGHT: Hi Anna Maria.

AMT: So we = know that Mr. Skripal and his daughter were poisoned with some kind of nerve agent. Is there a significance to the kind of poison that was used, Amy?

AMY KNIGHT: Well yes. From what I've learned this is not the kind of poison that would be easily available. So in other words would it suggest that whoever administered this poison could have gotten it from a state agent?

AMT: And why do you think - if Russian intelligence is behind this - why would it be now?

AMY KNIGHT: Well that's a good question and I've thought about quite a bit. I think it's really no coincidence that Putin has been so belligerent lately, you know talking about nuclear weapons he gave a speech to the Federal Assembly a couple of weeks ago, where he threatened the United States and said that Russia's missiles could penetrate our country without an anti-missile defence doing it being able to be effective. So I think that one way of looking at this poisoning is that it's part of an overall picture of the Kremlin increasingly standing up to the west and saying 'you can't push us around' and this appeals to the Russian audience. People are surprised I think but actually after all the information came out about the Litvinenko murder that Luke Harding was talking about, this British inquiry pretty much showed conclusively that two FSB assassins had poisoned Litvinenko. And the Russian public actually considered these two killers heroes because they assassinated a traitor, someone who betrayed the Motherland. So you know Russians are fed this steady diet of anti-Western propaganda and nationalism because the television which is the main source of news is state controlled. So you know this also does play to a Russian audience.

AMT: It's interesting because one of the men named in the Litvinenko thing was Andre Lugovoy he ends up in the Parliament. He gets elected.

AMY KNIGHT: Not only that but he also got a high state award from President Putin. So yes. And you know it's interesting Lugovoy a couple of days ago made a comment about this poisoning. He basically said 'this scum that ends up in Britain, that's Britain's problem'. It was really quite an incredible statement not overtly saying 'yes Russia did it' but basically saying 'it serves you right' to Britain.

AMT: Well in fact we talk a little bit more about the kind of spying that Sergei Skripal did for Britain but one person who vowed revenge was another former spy Russian President Vladimir Putin. This is him talking about Sergei Skripal in 2010.

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Traitors will kick the bucket. Trust me. These people betray their friends, their brothers in arms. Whatever they got in exchange for it, those 30 pieces of silver they were given, they will choke on them.

AMT: Give us an idea of what he was actually doing for Britain, Amy.

AMY KNIGHT: Well I think that, first of all, Skripal has been compared with Oleg Penkovsky the very famous spy who gave information to the British and the Americans. He was also from the GRU military intelligence and he was discovered and charged with treason and actually shot. So Skripal is being compared with Penkovsky in terms of the damage that he did to the GRU by revealing the identities of all these GRU undercover agents. So yes I mean there's no question that the Russian security services did not like Mr. Skripal.

AMT: But he was in prison with the Russians. He got caught. He was imprisoned, he ended up in a prisoner exchange which is why he's in Britain now, is that not right?

AMY KNIGHT: Yes that's correct. In 2010 he was sentenced earlier and he was sentenced to 13 years in prison. It's interesting. You know Russia doesn't have the death penalty, so they couldn't have Skripal killed like they did with Penkovsky. So this is kind of interesting. Well somebody has suggested that maybe when he was serving in a Russian prison they could have done away with them. You know it could have been an accident or something like that. But that misses the point. The point is the Kremlin I believe would like to send a message to other would be traitors 'this is what can happen to you'. So a high profile poisoning like this really sends a message. And as I said earlier it also sends a message to the west 'we can do what we want and we will get away with it.

AMT: Well and in fact it's very hard to prove which is the problem right now too.

AMY KNIGHT: Well yes and even with the Litvinenko case in 2006 there was this extensive British inquiry. I attended quite a few of the hearings and they came up with overwhelming evidence that the FSB was behind the assassination of Litvinenko mainly because the poisoned, Polonium 210, was only manufactured at one place and it was a heavily guarded government institution in Russia. So well there were all sorts of other circumstance, there were all sorts of other things that contributed to the conclusion that these two killers came from the Russian FSB. And I think it's going to be a little bit harder in the Skripal case. Because although t nerve agents are not readily available, it doesn't necessarily point to you know a specific enterprise that produced them.

AMT: We did see in North Korea an official have nerve agent rubbed in his face, at one point by someone not that long ago. Like we've seen other states use this, right.

AMY KNIGHT: Oh yes absolutely. And it was it was careless too, because now Skripal's daughter is in critical condition, two policemen were damaged. It's another very similar pattern because the same thing happened with the Litvinenko assassination. The killers inadvertently spread polonium all over London.

AMT: But you're making the point that if it is indeed Putin he's sending a message because the elections are coming up and he wants to send a message in relation to his own strength?

AMY KNIGHT: Well I think yes. I mean first of all it's a double message. It's a message to the west and to the Russian audiences. And you know Putin's for sure going to win the elections on March 18th. There's no doubt about that. But the Kremlin is very concerned that there's going to be a low turnout because the anti-corruption would-be-candidate Alexei Navalny was denied a place on the ballot and he has called for a boycott of the elections. So the Kremlin is concerned. It's important for Putin's image that there's a lot of support for him in these. And I think they're very concerned that the turnout will be quite a bit lower than it has been in the past. So when there's a big sort of Imbruglia with the West and suddenly attention is shifted to this dramatic event and Britain is saying things about Russia and the Russians are denying it. And then there's this underlying suspicion that actually they did do it. It may be difficult to understand but this plays very very well with Russian audiences.

AMT: Well Amy Knight we have to leave it there. Thank you so much for your time today.

AMY KNIGHT: Thank you.

AMT: That's Amy Knight. She's an expert on Russian politics. Her new book is called Orders to Kill: The Putin Regime and Political Murder. It's what she has documented it reads like a spy novel. She has in Summit, New Jersey. To hear my full interview with Vladimir Kara-Murza you can head to our website cbc.ca/thecurrent.

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AMT: The news is next and then: For years men of a certain age have heard the message 'get screened for prostate cancer to help with early detection'. Why that message may be changing after the news. I'm Anna Maria Tremonti. This is The Current on CBC Radio 1 and on Sirius XM.

Back To Top »

Early cancer screening can lead to unnecessary treatment and side-effects, study suggests

Guests: Stuart Edmonds, Richard Martin, Lorraine Hulley

AMT: Hello I'm Anna Maria Tremonti and you're listening to The Current.

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AMT: Still to come, the story of a most challenging surgery medically, physically, ethically. Dr. Allan Goldstein is a surgeon in chief at Boston's Mass General Hospital for Children. But even all his experience could not prepare him for a surgery to separate conjoined twins, 22 month old girls. You don't want to miss this story in about half an hour. But first, when early detection does more harm than good.

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AMT: Catch cancer early and you're more likely to cure it. That seems logical and there are plenty of messages out there urging people to be tested. The Man Van program run by Calgary's Prostate Cancer Centre urges men to give a simple blood test known as the PSA. They take their mobile clinic to public events. They'll be at the Calgary Auto Show next week, for example. We caught up with them yesterday at a private event in Calgary.

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VOICE 1: Hi I'm Art Bosch. I've been a volunteer with the Prostate Cancer Center since 2009 with the Man Van program, shortly after I was diagnosed with prostate cancer. Well right now we're in a warehouse where we're testing employees. The company has invited us in to do annual testing of their employees and we get a lot of that.

VOICE 2: You just put your name on there and then when you're done you go right into the Man Van.

VOICE 3: You know I just turned 40 and I just thought it's time. You know we go take that stuff serious. So it's convenient here and those are one of the biggest things. And of course you know when my work actually takes time out of our day to actually bring the Man Van down it's too easy. You know we can't say no.

VOICE 4: I had a good examination last year and wanted to make sure things hadn't changed. I think early detection is key. I had a father in law who passed away from prostate cancer. So I just want to make sure that if there's something going wrong I want to know earlier.

VOICE 5: My name is Megan Hurd. I've been a nurse on the Man Van for about a year and a half now. Most people are nervous about getting the girls so they're usually a little nervous so we try to keep it very upbeat and fun in the Van. Lots of joking lots of laughs. A lot of people have questions and wanting to know more so we do spend time answering those questions before we do the blood draws. But generally everyone lives very happy and are happy to know that it's an easy process that they can get all the results within a week.

VOICE 6: Hi my name is Martin Loakowski. And I've been volunteering with them than vans since 2012. I know there's some belief out there that PSA is no good. But I tell you what, you ask any survivor and 99 out of 100 are going to say a PSA test found it. So we had men come to the clinic. And they tell me that if not for the Man Van and getting tested that they wouldn't be talking to me right now, because they were diagnosed with it and the readings were fairly high. And by the time all the testing was done they had an operation or whatever it took to get it done and are living now.

AMT: The man Van program is run by volunteers and it is funded by donations. And the message to know your numbers definitely seems to resonate. A study published this week however cast doubt on that PSA test that is being offered. It was the biggest study of its kind, more than 400000 men. It was a long one. Each person was followed for ten years. It was randomized; the gold standard in medical research and it was published in one of the world's top journals the Journal of the American Medical Association. The researchers found men who did not get the test were no more likely to die than those who did. The results are adding fuel to an already fractious debate in the medical community and leaving patients wondering what to do. We're going to get to all of that but joining me first is the lead researcher of this study. Richard Martin is a professor of epidemiology at the University of Bristol. And that's where we have reached him, hello.

RICHARD MARTIN: Hi Maria.

AMT: First of all can you explain what the prostate specific antigen - the PSA test - is? What does it do?

RICHARD MARTIN: So PSA prostate specific antigen is a protein that's produced by the prostate gland. It's a protein which helps to produce healthy semen, healthy sperm. So it's present in the prostate gland. The problem is that small amounts of it can leak out of the prostate into the blood stream; particularly if the prostate gland is enlarged for example the prostate gland is infected. Then PSA leaks in the bloodstream and that's where it can be measured.

AMT: And so it measures if the numbers are higher. What's the concern?

RICHARD MARTIN: So if a PSA level is raised then that indicates that there may be an issue with the prostate gland. So it can be raised for a number of reasons. It can be raised if the prostate gland is enlarged. The prostate gland enlarges with age. It's a condition called benign prostatic hyperplasia. The PSA test can also be raised if there's an infection of the prostate gland and it can also be raised if there's a prostate cancer. But there are other things that can cause the PSA to rise, it can rise after ejaculation, it can arise if a man is a marathon cyclist for example. So there are a number of reasons why a PSA can be raised.

AMT: So let's talk about your study and your study was of men who were showing no symptoms. Am I correct?

RICHARD MARTIN: That's right. So so our study was what we call a population based study. We invited all men aged between 50 to 69 in a large number of practices across the UK to come for a PSA test and so these men were selected on the basis of symptoms. All of the men in the practice in that age group were essentially invited to come and discuss having a PSA test.

AMT: And what did the study find

RICHARD MARTIN: So we followed it up over 400,000 men you said who were aged between 50 to 69. That was between 2001 and 2009. Just to be clear the intervention was a single invitation to have a single PSA blood test followed by a biopsy. If the man had a raised PSA level the biopsy is required in order to make the diagnosis of prostate cancer. We looked at the number of prostate cancer deaths after an average of ten years follow up. We did find what we wanted to find that the incidence of prostate cancer in the intervention group was higher in the control group. The aim is to detect prostate cancer earlier and that's indeed what the trial found. We detected prostate cancer earlier and at higher levels than in the control group underwent a standard NHS treatment. In other words no screening. So the crucial The crucial finding was that there was no difference in the number of men who died of prostate cancer between the intervention groups - that's the men who are invited for the PSA screening - and the control group. So there were [unintelligible] point three percent of men died in both groups after the ten years follow up.

AMT: And you also looked at other risks of early detection.

RICHARD MARTIN: Not quite early risks. What we did look at is what kinds of cancer were being identified in the intervention. What we were hoping to do was to identify high-risk more aggressive prostate cancers so that we can treat those aggressive prostate cancers that need to be treated and prevent men dying from prostate cancer, while reducing the chance of side effects in men who would not benefit from treatment. What we found however was that 40 percent of the cancers that we identified in the intervention group were these low risk small prostate cancers. So we didn't actually reduce the number of low-risk prostate cancers are detected and it is those prostate cancers those lower risk prostate cancers that may not need treatment.

AMT: And it is those low risk cancers that are often treated, am I right, that cause other risks? Can you explain that?

RICHARD MARTIN: Yes so the issue with prostate cancer is that it's a very varied disease. Some prostate cancer is indolent and harmless and men will live with it all their lives. Some prostate cancer on the other hand is aggressive and will progress spread outside the prostate and could potentially harm. The problem with the PSA test is it can't distinguish between those two types of cancers; the slow growing harmless cancers that would never harm you and the more aggressive cancers. If you look at the natural history of prostate cancer, most prostate cancers take a very very long time to develop. You know in our study of the men who had localized prostate cancer, after an average of 10 years only 1 percent of the men with localised prostate cancer had died of prostate cancer, irrespective of whether they received radical treatment or they were actively monitored. So prostate cancer is a very varied disease. The PSA test cannot distinguish between those cancers that need treatment and can't and it's a very long term disease as well.

AMT: Right. But what's the problem with finding a low risk cancer and treating it?

RICHARD MARTIN: So the issue is that many of these low risk prostate cancers - and there are estimates that around 50 percent of prostate cancers that are identified through a screening program - could be prostate cancer that would never harm a man in his lifetime and essentially don't need treatment. So if a man is identified with a localized prostate cancer, we can't tell whether or not that prostate cancer is going to progress or if it's one that will never cause him any harm. The man then faces a difficult decision about whether he goes for radical treatment or is actively monitored. So if he goes for the radical treatment then the issues are that these are not trivial treatments and there are side effects for these treatments that could affect the quality of life.

AMT: Such as?

RICHARD MARTIN: So for example if he had surgery one of the commonest side effects is requiring absorbent pads because or urinary leakage.

AMT: Incontinence in other words.

RICHARD MARTIN: Incontinence in other words.

AMT: Right.

RICHARD MARTIN: But in our trial incontinence severe enough to have absorbent pads. A baseline in other words before the radical prostatectomy 1 percent of men were using absorbent pads within six months after the radical prostatectomy, 46 percent of men had to use pads. Now those side effects do recover but they do affect quality of life for a number of years.

AMT: Impotence is also where risk is it not?

RICHARD MARTIN: Impotence is a risk. And for example again in our trial the number of men with firm erections before they underwent radical prostatectomy, was around about 70 percent, 70 percent of men were potent. That dropped to 12 percent at six months after radical prostatectomy. Again there is recovery over time but still a large number of men are affected.

AMT: So in other words you're talking about the risk and quality of life and harm as well.

RICHARD MARTIN: Essentially what we're saying is that at the present time - and there are advances but at the present time - we do not have good test to distinguish between the men who have prostate cancers that need treatment and those who don't.

AMT: Well Richard Martin I'm going to stop you there because I want to bring someone else in. Stuart Edmonds is a vice president of research health promotion and survivorship at Prostate Cancer Canada, a charity that supports prostate cancer research and people living with prostate cancer. He's in our Toronto studio. Hello.

STUART EDMONDS: Morning.

AMT: What do you make of the results of what he's saying there?

STUART EDMONDS: Well I think they are really interesting results and kudos to Professor Martin, the team for publishing its data, it's really important data. I think one of the really interesting aspects of this data is that the study was really comparing an organized screening program to standard of care. And in the standard of care a number of the men were receiving PSA tests. It's not a sense that - you know other cohort sort of that have been published have been suggested to be almost dirty or contaminated because the control arm had PSA test. In this case it was actually expected because that's the standard of care. So so really I'm not actually surprised there was very little difference in the mortality in the two groups. I think the issue that we're facing in Canada is that many men aren't getting the standard of care. We have disparity across the country in that two out of ten provinces actually don't cover the cost of the test for asymptomatic men.

AMT: Right. He's essentially saying that if you have no symptoms - asymptomatic, right, and you go for the test and then there's a biopsy and maybe you're treated and there are false positives. And correct me if I'm wrong Richard Martin I'm just kind of cut to the chase here. But the risk of incontinence and impotence and further risk when you have a low cancer that would have done nothing to you is higher than the other one.

STUART EDMONDS: No absolutely. Professor Martin is right in that. You know we actually we need to do better actually diagnosing the aggressive forms of disease, the disease that the man would die of rather than the disease that a man would die with. And we don't have a good test to do that right now and to be honest we're investing quite a lot of money to understand how to how to distinguish indolent versus aggressive prostate cancer.

AMT: But is it the test or is it the biopsy that becomes the problem?

STUART EDMONDS: Well I think that's a really good point. You know as an entry point PSA isn't a bad entry point into the process because it provides information on an eminent urologist in Canada suggested recently that that actually as physicians they require more information or less information. It is what you do with that information that's important. So there is an entry point into the process of PSA isn't about entry point but it's not a diagnostic. It's really - the biopsy is seen as a diagnostic in more and more MRI is seen as a diagnostic.

AMT: MRI instead of a biopsy.

STUART EDMONDS: MRI reducing the number of biopsies.

AMT: And does that reduce the risk of other things? Does that help you understand the treatment better?

STUART EDMONDS: It may help you understand whether there is an aggressive disease and which ones you need to treat and which ones you don't need to treat. And in that respect Professor Martin touched on this the idea of active monitoring, active surveillance. And that is something that was really developed in Ontario, actually. We funded the initial grant in the early 90s to set up a cohort to look at men with very low risk disease this kind of indolent prostate cancer and followed them over a number of years and really see who you need to treat them. And so you monitor and you don't treat. You only treat the ones that actually you see the way the PSA rises or whether the biopsy suggests that something suspicious is happening. And recently there's data published in Canada that suggested that close to 80 percent of men that have a low risk disease aren't being treated. They're be monitored.

AMT: So Dr. Martin what do you think? I mean you're essentially saying the PSA test is a blunt instrument and that it doesn't it doesn't tell you enough. So what do you what do you think of what Stuart Edmonds is saying

RICHARD MARTIN: So what we are just talking about, what we all want is to reduce the detection and reduce overtreatment. So there are advances, I mean there’s this trial was started in the 1990s when the UK wanted evidence on whether or not to introduce prostate cancer screening. Since then of course there have been advances. And that said then there is the there is the possibility that multi parametric MRI scans that's magnetic field, that's imaging using magnetic fields may be better at identifying cancers are more aggressive and allow better sampling of the prostate cancer tissue to reduce the risks from the current biopsies. And that and that better imaging which is starting to look like it may be able to identify more aggressive cancers that better imaging combined with things like genetic testing and other protein markers may reduce over detection right. The second point is that reduction of overtreatment. And part of our trial was around looking at the effectiveness of this active monitoring that Stuart was talking about. When we followed up in the men who had low class prostate cancer we compared the act of monitoring versus the radical prostatectomy, versus the Radical radiotherapy. But after a meeting of 10 years between those three treatments there was no difference in prostate cancer mortality. Only 1 percent of the men after meeting of 10 years had died irrespective of which treatment they chose.

AMT: Stuart Edmonds I need you to just weigh in here because I am out of time. Stuart Evans What do you think of that?

STUART EDMONDS: Well no I think the that monitoring that was done in the protect study isn't how active [unintelligible] is being done now. So with all due respect I think the practice has changed now and I think we're much better at understanding the managing the low risk disease than we were 10 years ago. But nevertheless the issue in Canada is that we struggle with getting guys to go and get tested.

AMT: We have to leave it there. I'm going to hear from a patient advocate in a moment and we have to leave it there. Thank you both gentlemen. That's Richard Martin Professor of Epidemiology at the University of Bristol the lead author of the major study of the prostate cancer test in the Journal of American Medical Association. And Stuart Edmonds vice president of research, health promotion and survivorship at Prostate Cancer Canada. He's here in Toronto. Well it's confusing to patients when faced with competing or conflicting information. And my next guest is a patient advocate who helps people navigate medical minefields. Lorraine Hulley is president and founder of Pro Health Navigators Canada. She joins us from Fenwick, Ontario. Hi.

LORRAINE HULLEY: Good morning Anna Maria. Thank you for having me on.

AMT: Thank you for coming on. We just heard two people who really know this topic disagreeing. What is someone to think? Where do you get the final information?

LORRAINE HULLEY: Yes. Well in reality you have new information coming up all the time and I get calls regularly from patients and potential patients who are confused. And that's our information age. There's so many things on the Internet, there's so many things in newspapers. It can be certainly very confusing and being able to weed through that specific to one's current situation and how they're feeling is a really difficult choice, a difficult situation to be in.

AMT: And so a study that questions the power of the PSA testing, how do you help a patient figure that out?

LORRAINE HULLEY: Well I think you have to understand where are where the person's head at I mean for some people not having the test, as is part of Dr. Martin study, is perfectly fine for them. They're not information seekers; they're not necessarily wanting to have that information. You have other patients though that are very very keen and want to have that number. They hold on to that number is something that they can attest that whether or not their risk is high or low. I've had clients who have gone you know through a PSA process and had the watchful waiting and the yearly surveillance with their physicians. And you know and it's worked out really well for them. I think having that ability to be part of or into the system is, as Stuart was saying, it's a very good thing. There are some people though that get very concerned as their numbers start to go up. But again it's highly individual. I had a client recently who had their PSA double within a year. And their family doctor sent them right to an urgent appointment with a urologist. The urologist basically said 'yes your PSA has doubled but it's still low enough that we're not concerned'. They did a digital exam and found that the patient had a very large prostate and the doctor said you know what I would have expected your PSA to be much higher than what it is. So I am not concerned but we will be continuing to monitor you. So in his case he wasn't really concerned himself. The family doctor was more concerned but you know he will get the monitoring and at 78 years old he likely won't ever have any treatment.

AMT: So sometimes it's the questions we need to ask our doctors right. You help people with that?

LORRAINE HULLEY: Absolutely yes. And actually I give lectures in the public quite often about how to make the most of your healthcare experience. And you know I've got three top areas that I always say to people they need to really make sure that they cover: if you're going to see your doctor, a lot of times it's family members saying 'oh you've got that you really should see the doctor'. I always suggest to people that they write things down. They need to make sure that they've written down and I used an acronym that's used well in medicine. It's called the O P Q R S T acronym. So we all look for the onset and then when did it start. Secondly with P which is provoking and palliating side of things. You know what makes it better what makes it worse. Q Is the quality of if it's a pain or a pinch nerve or discomfort. Is it radiating is it? Is it annoying? What kind of pain or symptom are you having? R would be the radiating a referred pain. And that's something doctors need to know about. S As for the severity, is it something that wakes you up at night for instance? And then lastly would be the T would be the timing. What time of day does it happen because certain symptoms may come up at certain times of day.

AMT: So in other words if you share information with the doctor you get more information back and you can ask the other questions?

LORRAINE HULLEY: Absolutely. I always say to people write it down give a copy of this to your doctor and use that ten minute, that precious 10 minutes as a relationship builder but a business relationship builder. Don't go in there expecting to talk about golf.

AMT: OK well I guess some yeah it comes down to each individual. Lorraine Hulley we have to leave it there. Thank you for your time today.

LORRAINE HULLEY: Thank you.

LORRAINE HULLEY: Lorraine Hulley president and founder of Pro Health Navigator's Canada. She's in Fenwick, Ontario. Stay with us. Coming up in our next half hour, we're talking about an operation where the stakes could not be any higher. Dr. Allan Goldstein talks about the perilous surgery to separate conjoined twin sisters. I'm Anna Maria Tremonti This is The Current on CBC Radio One, Sirius XM, online on cbc.ca/thecurrent, on podcasts and on your radio app.

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A doctor explains his decision to perform life-threatening surgery on conjoined twins

Guest: Dr. Allan Goldstein

AMT: Hello I'm Anna Maria Tremonti and this is The Current. In his decades as a surgeon. This was something Dr. Allan Goldstein had never done before. He was about to separate two sisters, conjoined twins, in a Boston operating room. The family had travelled from overseas for the surgery. The girls were joined together just below the ribs. They were 22 months old. In most surgeries doctors go into an operating room expecting that if all goes well the patient will emerge in better shape than when they have entered. But things were different this time. Dr. Goldstein knew that even if all went well there was a high probability that one of those girls was going to die. It was an ethical conundrum the likes of which he had never experienced and it was an enormously complex surgical challenge as well. Dr. Allan Goldstein is the surgeon in chief at the Mass General Hospital for Children in Boston and we reached him in Boston. Hello.

DR. ALLAN GOLDSTEIN: Hello. Thank you for having me.

AMT: Tell me about these girls. How did you find out about them?

DR. ALLAN GOLDSTEIN: We were contacted by a foundation who was aware of their situation and the need for them to get sort of taken care of and the inability to find care locally. And so that foundation reached out to me via e-mail.

AMT: And what had life been like for the family up until that point?

DR. ALLAN GOLDSTEIN: Their life was very difficult. These babies were born in a village in East Africa. And in that particular community they were stigmatized because these children did not look normal. They found that hard not just to receive any medical care, they found that hard to go out in public people would throw stones at them. And it was really an untenable situation for them.

AMT: Now you say it's East Africa you haven't identified the country there for very specific reasons.

DR. ALLAN GOLDSTEIN: The family's worried about what would happen to them and the relatives that are still in that country. The issue is that not only were they stigmatized for having these children and maybe the sense locally that - I don't know how to say that - they were sort of marked as you know maybe sort of seen as an evil mark on them. But even worse was the concept that they would undo what God had done by trying to separate them. They left the country seeking care first in another country that was unable to provide the care that was necessary and when they did leave their family who remained behind was threatened. And so we've maintained their anonymity.

AMT: And why did the parents decide they wanted to try to get surgery for their girls?

DR. ALLAN GOLDSTEIN: They really wanted to do something to make the life of their daughters better. They felt that it was not a situation that they could continue to live and particularly in their home country. These girls were attached and facing each other they had to lie down there was no way to set them up. It was difficult to carry them. It was even difficult to diaper them or clothe them.

AMT: So what was it like meeting the family for the first time?

DR. ALLAN GOLDSTEIN: They were so excited to be in the U.S. and to at least have the opportunity to do something for their children. But we made it clear long before they arrived that we could guarantee nothing. We would try to do our best to help them. We may not be able to offer an operation and even if we could we couldn't guarantee that one or either of the children could survive, understanding the complexity of it.

AMT: Tell me a little bit more about the girls.

DR. ALLAN GOLDSTEIN: The girls were what we call them fellow Omphalo-Ischiopagus. That means that they were attached that the abdomen and the pelvis. It's almost like a Y shape. They had two heads and two chests and then the rest of the body was a single body although it had three legs. They had four arms. They were clearly two different distinct individuals. One was very playful. She was active, energetic, she loved to play with the doctors and nurses. She also played with her sister although her sister, who we refer to as Twin A, was smaller, more subdued, less active.

AMT: And when you met them like what was your interaction with them like?

DR. ALLAN GOLDSTEIN: Like any interaction that a paediatric specialist has with a child. It was all about just playing with them and seeing- you know you try to gauge sort of their level of activity, their developmental stage. It was clear that Twin B was a little more advanced and not only in terms of physical development but in terms of her interactions with others. But it was wonderful. It was clear that I was interacting with two children although they shared one body.

AMT: And what made you think this operation was possible?

DR. ALLAN GOLDSTEIN: Before they came. They sent us a CAT scan that was done in that first country that they went to. And many conjoined twins are attached by the heart or they're attached by the head. And in those cases the chances of separating and doing a successful operation are low. In this case because they had only their attachment was limited to the abdomen and pelvis. We sort of we took that as a good sign that there was an increased likelihood that separation could be achieved. Based on those rudimentary CAT scans we invited them to come, again with no guarantee but when they arrived we were able to do much more imaging then we got to the situation that we could say that surgery was feasible. But then there was a twist that made us question, while it's feasible, was it the right thing to do.

AMT: And what was that test?

DR. ALLAN GOLDSTEIN: It turned out that Twin A and B shared non vital organs. You know the vital organs would be the heart, the brain, that they shared intestine liver. They had one pelvis. So they had one bladder, one colon, rectum, one anus and vagina. All of that can be separated and you can even reconstruct those organs in the other twin. But the problem was when we got into more detail of imaging the heart's. While Twin B had a relatively normal heart, Twin A's heart was was very abnormal. She just had an anatomy and a physiology to that heart which is not sufficient to generate the blood flow and the blood pressure that is necessary to support her circulation.

AMT: This is the smaller twin.

DR. ALLAN GOLDSTEIN: The smaller one. It was clear that she was alive because her sister was providing her life support. And she was doing that because Twin B's heart, which was very healthy, was pumping blood through a large artery that went from the aorta of Twin B over to the aorta the Twin A. And without that life support twin they would have already died long before.

AMT: Wow. So this is not something you had any idea of ahead of time.

DR. ALLAN GOLDSTEIN: No there was no way to do that with the imaging that we had gotten prior to their arrival. But we were fortunate to get some like three dimensional cat scans where we could see in detail the heart anatomy and the blood vessel anatomy that made it clear that Twin A had her heart and lungs were such that she could not live independently of Twin B.

AMT: What kinds of ethical reviews does the surgery such as that have to go through, then, as you look at what's possible and you look at the anatomy?

DR. ALLAN GOLDSTEIN: We have an excellent paediatric ethics committee. Their job I don't think is so much to tell us what to do but rather to frame the problem in a way that we can then all think about it, and not just us as clinicians but then also how do we explain it to the parents. Because ultimately in this situation they have the say in what gets done. The framing of the problem really boiled down to asking four fundamental questions. The first is this one person or two people that we're dealing with. You can imagine a situation where the conjoined twins share an upper body and just have separate lower bodies. So you know if they have one head and one chest really just one face it be hard to see that it's two individuals. This was a very different situation. It was clear that we were dealing with two children. And then the question is what is possible surgically, medically. And we came to the conclusion that it was possible to separate them. That leaves us really with two questions. If we separate them we know that there is a high likelihood that the smaller twin will die. So the ethicists at Mass General Hospital for Children asked us 'is it ever morally acceptable to sacrifice one child for another? And if it is who should make that decision?' So those are the issues we were confronted with. And in the end we made the- You know it's a hard decision and one that I hope I don't have to make very often - we as doctors do everything in the best interest of the patient. That's our fundamental role is to figure out what's best for the patient and do that. But in this case what's in the best interest of one patient may not be in the best interest of the other. We talked to the parents at length. They had support, social support, religious support and came to the conclusion that if we did nothing the smaller twin would clearly die. She was already getting sick over the period of weeks that she was in the U.S. If she died the other twin would certainly die relatively soon just because of the release of toxins and chemicals from the dying Twin A. So if we didn't nothing we would see them both die and in action leading to the death of two children seemed sort of not palatable to the team, nor was it what the family wanted. The family - the parents - were clear that they wanted both to live but if they both couldn't live they wanted at least one to live. And they said that they could not maintain the current situation. They wanted an attempt to separate understanding that in the end they may end up with neither child. They understood that and were willing to take that risk and we felt that to save the life of one even if it meant that the other may not survive. Made sort of the most sense among these difficult and sort of undesirable choices on both sides.

AMT: At some point you realized that many other places had turned them down.

DR. ALLAN GOLDSTEIN: I'm lucky I didn't know that. I only heard that later. The representative from the Foundation came to visit us after the procedure had been finished. And then told me that over 20 other hospitals had been asked to whether they would do this and all of them had turned them down.

AMT: And had you known that it would have been a tougher decision at that point?

DR. ALLAN GOLDSTEIN: You can't help but second guess your judgement thinking that while all these other people think this is not a good idea it would be awfully arrogant to say no but I know it's a good idea. In the end I'm glad I didn't know because I'm very happy in retrospect that we took on this case.

AMT: So let's talk about the surgery. How many people are involved in a surgery such as that?

DR. ALLAN GOLDSTEIN: In the operating room we probably had I think a team of 12 surgeons. We had two teams of anaesthesiologists for each of the two children and then the team of nurses and all the perioperative staff. But to get to that point was you know all of the medical specialties; cardiology played an important role; radiology; the intensive care doctors; social work had an important part to play as did palliative care; nursing. So really we put together a team of about 100 to 150 people at Mass General Hospital for Children that made this all possible.

AMT: How long a process is something like this? Is it just the preparation to get to the point where you can actually have the team to go into the OR?

DR. ALLAN GOLDSTEIN: The preparation was the operation itself seemed trivial actually. The anticipation of it, the preparation involved because we needed to map out every stage of this operation which took 14 hours, we needed to know who's going to go first, how long will they take, what will the second team do so that we could coordinate everything. We were planning to spend really a couple of months figuring everything out, but Twin A started to get sick. Within ten days of arriving in the country, she developed an upper respiratory infection and she was in such a tenuous condition that that really created a challenge for her. She ended up in- they ended up together in the pediatric ICU for ten days. And even though she got better, she was back a week later. We needed to push everything up and it's hard to just suddenly schedule something like this. But we were able to get the operation on the schedule about one month after their arrival in Boston.

AMT: Not all the doctors had been consulted agreed to go ahead. Why was that?

DR. ALLAN GOLDSTEIN: You know it is a hard decision to make to know that you're going to go into the operating room with two patients and almost certainly leave with at most one. We had three physicians who felt that that was never right, that a doctor should never contribute to the death of a patient. And so they had the choice of whether or not to participate and opted not to. We respected that choice understanding that for all of us it was a difficult decision.

AMT: So walk us through the surgery itself, how did it unfold?

DR. ALLAN GOLDSTEIN: The first step was getting the kids to sleep and that in itself was a challenge because you have two faces right next to each other and breathing tubes have to be put in, all the I.V. lines and monitors and once that was done the next question is how do you make an incision. You have to be sure that knowing that Twin B is hopefully going to survive, you can't use any of Twin A's skin because it won't be provided with blood by Twin B's heart. So we need to know which skin is provided blood by which baby's heart. So our plastic surgeons injected a fluorescent dye into the blood through an I.V. in Twin B. And using a special monitor they could see which part of the skin lit up with that fluorescent dye, that was clearly Twin B skin and needed to stay with Twin B and they designed the incision that way let us get into the abdomen to separate the liver. Next we divided the intestine. So we were able to separate all the abdominal organs and then the orthopaedic surgeons came and dealt with the pelvis. So after the orthopaedic surgeons were done we did what I have no doubt was the hardest part of the operation for me personally. There was this big artery that I mentioned, extending from the aorta of Twin B to Twin A. It's an artery we all have it normally just supplies the small intestine. But in this case this artery was supplying life support to the Twins A and it was ten times larger than normal. It was the size of her aorta. So we needed to divide that artery. We left it for the last because we knew that the moment we divided it Twin A would likely die. And so that was the last thing we did. We divided the artery and her blood pressure dropped significantly. Her oxygen level dropped. An attempt was made to help her with medicines and more fluids. But it was a risk because anything we did still to Twin A - they they were still attached by a lot of soft tissue and skin - potentially those drugs would go for the Twin B and affect her. So she died within 10 minutes of dividing that blood vessel. At that point the rest of the skin and soft tissue was separated. The plastic surgeons stayed with Twin B to close the body. And I took Twin A to another operating room. We had saved that operating room next door on the off chance that many of us hoped for that may be Twin A could survive. But it turned out that we just used that operating room to close her and wrap her up so that we could bring her to her family so they could say goodbye.

AMT: So you knew when that artery was going to be cut that that was likely going to happen. What was going through your mind?

DR. ALLAN GOLDSTEIN: I think I knew the whole time long before the operation that she would die. I held out this little bit of hope that maybe there was something we didn't understand, maybe there was the possibility that that heart was good enough to keep her alive at least briefly. I was hoping that the family could at least see a living daughter. And in that way spend a few hours with her when she died it was incredibly painful. And that's despite weeks of preparation and talking about it. But in paediatric surgery we rarely go to the operating room with a child then leave without that child. It was very painful for me.

AMT: How did you react?

DR. ALLAN GOLDSTEIN: We had a third operating room that was where the staff could rest because it was such a long and emotional day. I went to that spot and I cried.

AMT: Were you surprised at your own reaction?

DR. ALLAN GOLDSTEIN: I was. I mean I've I don't make it a habit of crying in the operating room but I will tell you that in pediatrics it's very impactful when a child dies. And every now and then it happens and it's horrible. And all of us need you know support to be able to get through that. It is very very difficult. I had developed a relationship with both girls and certainly with the parents. I saw them every day for a month or so and it was hard to lose her.

AMT: And I guess that's the question did you let one die or did you help one live?

DR. ALLAN GOLDSTEIN: That's such an important question. We needed to see this, not that we were going to end the life of one child in order that the other child would live. The goal was the exact opposite. It was that we wanted to save the life of a child. And in doing so the other twin would die. And I think that that framing it that that is the intent, it makes it a little bit easier to cope with, to understand and hopefully to see that we did what we think was best. If they were adults we would ask them what would you like to do. And I would think that the weaker twin if asked 'do you want to be separated or do you want to die together?' Maybe the weaker twin would have said 'no. It's best that my sister live on'. I'll never know. I hope that we made the right decision. The parents feel that we made the right decision and that was very important.

AMT: And I know that this was a difficult decision for you. You talk to your daughter about this. What did she ask you?

DR. ALLAN GOLDSTEIN: I don't know how my daughter who's 14 asked me this but she asked me if I had violated the Hippocratic Oath, and of all the times that I've talked about this operation nobody had asked me that. And it definitely stunned me. I don't know the answer. We try to do what we think is best for a patient, for their family. We do it in consultation with experts, other doctors, ethicists and we do it in concert with the wishes of the patient or if their children with their wishes of their parents. So I'll never have an answer to my daughter except to say that I think we did the right thing.

AMT: And how is the surviving girl?

DR. ALLAN GOLDSTEIN: She's doing really well. She only stayed in the hospital a few weeks. She then had extensive rehab. She has two legs but one of them has a severe congenital anomaly. It's an unusual situation where the foot is duplicated. There's a central big toe and then three little toes on either side of it. And that duplication extends up to the knee. She can't walk and that leg is too abnormal really to allow her to walk in the future so she'll need more surgery. But amazingly her bowel function is normal. Her urinary function is normal. She's incredibly fun, she's always smiling. She has wonderful parents who take care of her. She really looks- if you just looked at her she looks entirely like a normal child.

AMT: How old is she now?

DR. ALLAN GOLDSTEIN: She is now three and a half.

AMT: Does she know her sister is gone? Does she have a sense of that?

DR. ALLAN GOLDSTEIN: She must. Because when she came early on for a post-operative visit, it must have been just a few months after surgery, I gave her a stuffed animal a teddy bear as a gift and she took it. She was really happy and she said something to her father. And I asked him what she said. And he said she said it's her sister.

AMT: And what about her parents. How are they doing with the loss of one daughter and the change in the other?

DR. ALLAN GOLDSTEIN: I think they coped very well with it as well as you could hope that parents could deal with such an incredibly difficult situation. The day after she died the mother stayed in the intensive care unit with the daughter and the father together with the cousin and the chaplain went off to bury the other child. After that, they really didn't look back. They were comfortable with the decision they had made. They did not regret it. And they are thrilled to have a beautiful daughter with them.

AMT: Do you know, can they go home, given what was there when they left?

DR. ALLAN GOLDSTEIN: Yeah that's a real challenge. They're afraid to go home. And that's unfortunate. So I think their best stuff here but it is hard for the family that stayed behind.

AMT: And so when you think of all that you went through with that family and those two little girls and how it all came to be at the end. I'm wondering what stays with you now?

DR. ALLAN GOLDSTEIN: Oh I will never forget that day in the operating room. But what really - aside from the emotional sort of difficulty dealing with all of that - was just the respect for my colleagues. It is truly the basic principle of what we do as physicians, especially physicians who take care of children, everybody this is like at least 150 people were focused on just doing what's best for that family. I could imagine no better way to spend the career than to spend that with people who just care about doing what's right for other people.

AMT: Dr. Goldstein It's important for us to hear you thank you so much.

DR. ALLAN GOLDSTEIN: Thank you very much.

AMT: Dr. Allan Goldstein as surgeon in chief at Mass General Hospital for Children in Boston. He's a professor of surgery at Harvard Medical School. He spoke to us from Cambridge, Massachusetts. Now a word from the team that put the show together this week.

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JOHN CHIMAN: Hello I'm John Chipman one of the producers here at The Current. This week the show was produced by: Alison Masemann, Geoff Turner, Howard Goldenthal, Idella Sturino, Jason Vermes, Ines Colabrese, Julie Crysler, Kristin Nelson, Liz Hoath, Pacinthe Mattar, Rosa Kim, Samira Mohyeddin, Karin Marley and Yamrie Taddese. Special thanks this week to Anne Penman in Vancouver, Suzanne Dufresne in Winnipeg, Laurene Jardin in Montreal, and Mary-Catherine McIntosh in Halifax. Our intern is Danielle Carr. The Current's writer is Peter Mitton. Our web producer is Lisa Ayuso. Our digital producer is Padraig Moran with help this week from Sarah Claydon. Our documentary editor is Joan Webber. Transcriptions are provided by Rasha Shehata and Nikhil Sharma. Our technical producer is Gary Francis. Our senior producers are Willow Smith in Toronto and Cathy Simon in Vancouver. The executive producer of The Current is Lara O'Brien.

AMT: That's our program for today's day with Radio 1 for Q with Tom Power. Duncan McCue is here tomorrow with our third public forum Facing Race, was recorded in Montreal earlier this week. Duncan McCue and Facing Race tomorrow on The Current. We were talking earlier about prostate cancer, whether men should seek PSA screening. The British actor writer and wit Stephen Fry revealed last month that he has prostate cancer. The 60 year old released a YouTube video about his cancer. He described it as "an aggressive little bugger". He underwent an operation in January to remove his prostate. We're going to leave you with Stephen Fry and his video about the ordeal. I'm Anna Maria Tremonti. Thanks for listening to The Current.

SOUNDCLIP

You know in the end that's a word that just rings in your head 'Cancer. I have got cancer'. I went around saying to myself 'I've got cancer. Good heavens. Stephen, you're not supposed to gets cancer'. I mean I know it's an old cliché but you don't think it's going to happen to. Cancer is something it happens to other people. You're probably now looking into my eyes and seeing 'Oh yes I can see. He is kind of cancery person. I can see that'. That's how one looks at people who've got cancer and I always wonder if there is particular smell or a particular odour that give off of that 'cancer'. What a horrible word it is. It's one of our real taboo isn't it. I know of a woman who couldn't even say it. She couldn't say death or killed or died or any of those words or cancer. She once described someone as having 'ehem'. It's just one of those shocking, hard, difficult words. But for the moment I'm fitting well and happy and I just wanted to let you know. So they you are, Stephen Fry. My fights with cancer, of course it wasn't a fight. I just submitted and that the surgeon and the surgeon Ben was wonderful and Roger the urologist was wonderful and [unintelligible] my daughter wonderful. Generally felt my life was saved by this early intervention

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